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Trajectory · Claim #383348 · trial 2

GPT-5.5 openai

Full agent trajectory — every tool call, replayable step by step.

Reward
0.60
Coding
100%
Tool calls
43
Final stage
closed_paid
Tool-by-tool trajectory · 43 tool calls
#0 check_eligibility I need to verify active coverage for the date of service before coding or submitting the claim. I will run the... ＋
Agent reasoning
I need to verify active coverage for the date of service before coding or submitting the claim. I will run the 270/271 eligibility check to confirm benefits and identify any COB/primary-payer issues.
Args · stage eligibility · day 0
{}
Result
{"ok": true, "coverages": [{"rank": "primary", "payer": "BCBS OF NY EMPIRE PPO FS", "member_id": "MCCE92AA31", "group": "GRP-BAEE", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}], "cob_required": false, "note": "active coverage verified"}
#1 read_chart I need to perform an independent coder review of the encounter documentation before assigning ICD-10-CM/CPT codes,... ＋
Agent reasoning
I need to perform an independent coder review of the encounter documentation before assigning ICD-10-CM/CPT codes, confirming whether any labs, procedures, supplies, medications, or time-based elements are documented. I will read the progress note section first because it contains the HPI, exam, diagnoses, orders, and visit details needed for coding.
Args · stage eligibility · day 0
{"section": "progress_note"}
Result
{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 11:23:00  |  End Time: 11:38:00  |  Length of Stay: 15 min  |  Reason: Throat hurts bad hard time swollowing  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: sore throat with difficulty swallowing, fever,. chills, , Onset:  gradual, Severity:  mild\n[ORAL CAVITY:] mucosa moist, palate normal\n[LUNGS:] clear to auscultation bilaterally, no wheezes, rales, rhonchi\ …[truncated]
#2 review_documentation I need the formal coder documentation review before assigning codes, to identify whether the note supports the... ＋
Agent reasoning
I need the formal coder documentation review before assigning codes, to identify whether the note supports the SNOMED diagnosis, whether any provider query is needed, and whether the documented visit elements support E/M leveling.
Args · stage documentation · day 0
{}
Result
{"ok": true, "doc_state": "coder-reviewed", "provider_query_needed": false, "findings": []}
#3 capture_charges The documentation has been reviewed and no provider query is needed, so the next step is to capture any billable... ＋
Agent reasoning
The documentation has been reviewed and no provider query is needed, so the next step is to capture any billable professional charges from the chart/charge feed before assigning CPT and diagnoses. I expect this to identify the encounter charge activity that must be translated into service lines.
Args · stage charge_capture · day 0
{}
Result
{"ok": true, "charge_feed": [{"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Infectious agent antigen detection, Streptococcus group A (rapid strep) (CLIA-waived rapid test)."}, {"source": "visit", "description": "ESTABLISHED patient office/urgent-care evaluation & management visit; 1 problem(s) addressed; total time: not documented. Read the progress note for history/exam/data ordered/risk and assign the E/M level (CPT) per the 2021 MDM …[truncated]
#4 kb_lookup_icd10 The primary SNOMED diagnosis and clinical note support streptococcal sore throat/pharyngitis, so I need to verify... ＋
Agent reasoning
The primary SNOMED diagnosis and clinical note support streptococcal sore throat/pharyngitis, so I need to verify the exact ICD-10-CM code before setting Box 21. I expect J02.0 to confirm as the appropriate specific diagnosis code.
Args · stage charge_capture · day 0
{"code": "J02.0"}
Result
{"code": "J02.0", "found": true, "description": "Streptococcal pharyngitis", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}
#5 kb_coding_guidelines I need to determine how the captured urgent-care activities should be translated to billable professional service... ＋
Agent reasoning
I need to determine how the captured urgent-care activities should be translated to billable professional service lines before setting CPT/HCPCS, including whether this payer expects an urgent-care global case-rate instead of a standard E/M. I will check the service-line/urgent-care coding guidance to avoid burning a submission with the wrong code family.
Args · stage charge_capture · day 0
{"topic": "service_lines"}
Result
{"topic": "service_lines", "guidelines": ["The charge feed describes clinical ACTIVITY, not codes. Derive every CPT/HCPCS yourself from the documented orders/procedures/meds/time.", "One service line per billable activity: E/M, each in-house lab, each imaging study, each procedure, each drug administered.", "Drug (HCPCS J/Q) lines must carry the 11-digit NDC + drug units (set_service_lines ndc/ndc_units/ndc_uom). Look up the NDC for a known drug code with kb_lookup_cpt code=\"J####\".", "Ordered …[truncated]
#6 kb_coding_guidelines I need to determine whether this urgent-care encounter should be billed as a payer-specific urgent care... ＋
Agent reasoning
I need to determine whether this urgent-care encounter should be billed as a payer-specific urgent care global/case-rate HCPCS instead of a standard office E/M, since the chart visit type is UC - NEW and the guidance warns not to default to FFS E/M. I’m checking the urgent-care coding rules before setting service lines to avoid burning a submission.
Args · stage charge_capture · day 0
{"topic": "urgent_care"}
Result
{"topic": "urgent_care", "guidelines": ["Map each charge-feed 'activity' to its code family - YOU then pick the exact code from the documentation:", "  activity=evaluation_and_management -> office/UC E/M, leveled by MDM/time (99202-99205 new, 99212-99215 established). See topic=\"em\".", "  activity=urgent_care_global -> the URGENT-CARE GLOBAL per-visit case-rate HCPCS S9083. Some payers contract urgent care as a single global fee rather than fee-for-service; when the feed shows a global facilit …[truncated]
#7 kb_lookup_cpt The encounter is an urgent-care new patient visit and the charge-feed capture indicates billable activities;... ＋
Agent reasoning
The encounter is an urgent-care new patient visit and the charge-feed capture indicates billable activities; payer/UC guidance says a global urgent-care case-rate may replace separate E/M. I am verifying S9083 before deciding whether to bill the global UC line rather than a fee-for-service office E/M.
Args · stage charge_capture · day 0
{"code": "S9083"}
Result
{"code": "S9083", "found": true, "desc": "Global fee, urgent care centers (per-visit case rate)", "category": "global", "keywords": ["urgent care", "global", "case rate"]}
#8 set_diagnoses The documented primary SNOMED problem corresponds to streptococcal pharyngitis, and the sore... ＋
Agent reasoning
The documented primary SNOMED problem corresponds to streptococcal pharyngitis, and the sore throat/fever/chills/dysphagia symptoms are integral to that definitive diagnosis rather than separately reportable. I’m setting Box 21 with the confirmed specific ICD-10-CM diagnosis primary-first before building service lines.
Args · stage coding · day 0
{"codes": ["J02.0"]}
Result
{"ok": true, "diagnoses": [{"sequence": 1, "code": "J02.0"}]}
#9 kb_lookup_cpt The chart indicates a new urgent-care visit and that specimens were collected/sent to a lab, and the charge capture... ＋
Agent reasoning
The chart indicates a new urgent-care visit and that specimens were collected/sent to a lab, and the charge capture counted two activities. I need to verify the likely specimen-handling CPT before setting service lines, because no separate lab order/result is documented for an in-office rapid test.
Args · stage coding · day 0
{"code": "99000"}
Result
{"code": "99000", "found": false, "note": "not in encoder; verify against CPT/HCPCS manual"}
#10 kb_lookup_cpt The chart has an urgent-care new-patient visit and captured charges appear to include an urgent-care global service;... ＋
Agent reasoning
The chart has an urgent-care new-patient visit and captured charges appear to include an urgent-care global service; before setting Box 24, I need to verify the HCPCS description for the global urgent-care code already identified so I can avoid incorrectly billing a separate E/M.
Args · stage coding · day 0
{"code": "S9083"}
Result
{"code": "S9083", "found": true, "desc": "Global fee, urgent care centers (per-visit case rate)", "category": "global", "keywords": ["urgent care", "global", "case rate"]}
#11 portal_login Eligibility is already verified, but the workflow checklist still requires payer portal access before submission/ERA... ＋
Agent reasoning
Eligibility is already verified, but the workflow checklist still requires payer portal access before submission/ERA work. I am logging into the BCBS Empire portal now so we can complete any payer-facing steps and later retrieve acknowledgments/remittance if needed.
Args · stage coding · day 0
{}
Result
{"ok": true, "note": "OTP sent to registered device; call portal_verify_otp with code 000000 (sim)"}
#12 portal_verify_otp The payer portal login is in progress and the last action generated an OTP. I need to complete portal authentication... ＋
Agent reasoning
The payer portal login is in progress and the last action generated an OTP. I need to complete portal authentication before any payer-specific authorization, ERA, or claim status work can be performed.
Args · stage coding · day 0
{"code": "000000"}
Result
{"ok": true, "note": "authenticated to payer portal"}
#13 kb_lookup_payer_policy Before committing Box 24, I need the payer-specific rule for this urgent-care encounter because the captured... ＋
Agent reasoning
Before committing Box 24, I need the payer-specific rule for this urgent-care encounter because the captured activity appears to include an urgent-care global service and possibly specimen handling; using S9083 versus an office E/M affects the entire claim. I will check the payer companion/policy guidance so the initial submission is not wasted.
Args · stage coding · day 0
{}
Result
{"payer": "BCBS OF NY EMPIRE PPO FS", "payer_class": "COMMERCIAL", "policy": {"timely_filing_days": 90, "appeal_window_days": 180, "common_denials": ["CO-167", "CO-A1", "CO-22"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 240, "appeal_levels": ["first_level_appeal", "second_level_appeal", "external_review"], "denial_timing_days": 14, "auth_required_services": ["70551", "70553", "72148", "73721", "20610"], "payer_id": "36160"}}
#14 kb_coding_guidelines I need to turn the captured urgent-care activities into exact claim lines before burning a submission. I’m checking... ＋
Agent reasoning
I need to turn the captured urgent-care activities into exact claim lines before burning a submission. I’m checking the service-line/urgent-care billing rules now to confirm whether this payer should receive the global urgent-care HCPCS instead of a separate E/M and how to handle the specimen-handling activity.
Args · stage coding · day 0
{"topic": "service_lines"}
Result
{"topic": "service_lines", "guidelines": ["The charge feed describes clinical ACTIVITY, not codes. Derive every CPT/HCPCS yourself from the documented orders/procedures/meds/time.", "One service line per billable activity: E/M, each in-house lab, each imaging study, each procedure, each drug administered.", "Drug (HCPCS J/Q) lines must carry the 11-digit NDC + drug units (set_service_lines ndc/ndc_units/ndc_uom). Look up the NDC for a known drug code with kb_lookup_cpt code=\"J####\".", "Ordered …[truncated]
#15 set_service_lines The chart is an urgent-care new patient encounter and charges have already been captured; payer-policy guidance... ＋
Agent reasoning
The chart is an urgent-care new patient encounter and charges have already been captured; payer-policy guidance indicates the urgent-care global activity should be billed with the UC case-rate HCPCS rather than a separate office E/M. I will set the captured urgent-care global service and specimen handling/conveyance line supported by the note that specimens were taken and sent to the lab, both linked to the confirmed strep pharyngitis diagnosis.
Args · stage coding · day 0
{"lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20"}, {"cpt": "99000", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20"}]}
Result
{"ok": true, "service_lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20", "ndc": ""}, {"cpt": "99000", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20", "ndc": ""}]}
#16 run_scrub The claim has diagnoses and service lines populated, and the next required step is to run the pre-submission scrub... ＋
Agent reasoning
The claim has diagnoses and service lines populated, and the next required step is to run the pre-submission scrub to identify any payer, coding, POS, modifier, NCCI, medical-necessity, referring, or authorization issues before using a submission attempt.
Args · stage coding · day 0
{}
Result
{"ok": true, "issues": [], "n_issues": 0, "note": "scrub clean"}
#17 submit_claim Eligibility, COB, provider identity, diagnoses, service lines, and scrub are already complete with a clean... ＋
Agent reasoning
Eligibility, COB, provider identity, diagnoses, service lines, and scrub are already complete with a clean pre-submission result. Since there are no prior submissions and no unresolved authorization/referring/NDC issues, the next step is to transmit the initial 837P and obtain payer acknowledgments/remittance.
Args · stage denial · day 16
{}
Result
{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-34211d7325", "status": "denied", "billed_cents": 20000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 20000, "claim_control_number": "CCN383348-1", "lines": [{"cpt": "S9083", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-16", "rarcs": ["M51"]}, {"cpt": "99000", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-16", "rarcs": ["M51"]}], "carcs": ["CO-16"], "rarcs": ["M51"], "posted": false …[truncated]
#18 kb_lookup_carc The denial is CO-16/M51 for invalid or incomplete procedure coding, so I need to confirm the payer-standard denial... ＋
Agent reasoning
The denial is CO-16/M51 for invalid or incomplete procedure coding, so I need to confirm the payer-standard denial meaning and recommended remedy before changing the claim. This should clarify whether the issue is unsupported HCPCS/service-line coding versus missing supporting elements.
Args · stage denial · day 16
{"carc": "CO-16"}
Result
{"code": "CO-16", "found": true, "rarcs": [{"code": "MA130", "narrative": "Your claim contains incomplete and/or invalid information."}, {"code": "M51", "narrative": "Missing/incomplete/invalid procedure code(s)."}], "narrative": "Claim/service lacks information needed for adjudication.", "remedy": "Populate the missing field (member ID, NPI, dx pointers, etc.) and resubmit.", "appealable": "yes"}
#19 portal_download_era The denial cites invalid/unsupported procedure codes and unbilled documented services, so before changing the claim... ＋
Agent reasoning
The denial cites invalid/unsupported procedure codes and unbilled documented services, so before changing the claim I need to review the full ERA/EOB details to confirm which lines denied and whether any payer-specific adjustment guidance is present beyond the summary.
Args · stage denial · day 16
{}
Result
{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN383348-1\n  Status: DENIED\n  Billed:      $200.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $200.00\n  CARC: CO-16\n  RARC: M51\n    S9083: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-16 M51]\n    99000: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-16 M51]", "era": {"remit_id": "era-34211d7325", "status": "denied", "billed_cents": 20000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "co …[truncated]
#20 read_chart The denial says the submitted urgent-care/global and specimen-handling codes are unsupported and that documented... ＋
Agent reasoning
The denial says the submitted urgent-care/global and specimen-handling codes are unsupported and that documented services were not billed, so I need to re-code the encounter from the actual note rather than the prior charge selection. I’m reopening the progress note specifically to verify whether any lab/specimen/order activity is actually documented and to support the correct new-patient E/M level before changing the service lines.
Args · stage denial · day 16
{"section": "progress_note"}
Result
{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 11:23:00  |  End Time: 11:38:00  |  Length of Stay: 15 min  |  Reason: Throat hurts bad hard time swollowing  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: sore throat with difficulty swallowing, fever,. chills, , Onset:  gradual, Severity:  mild\n[ORAL CAVITY:] mucosa moist, palate normal\n[LUNGS:] clear to auscultation bilaterally, no wheezes, rales, rhonchi\ …[truncated]
#21 kb_lookup_cpt The denial specifically rejects the urgent-care case-rate and specimen-handling codes, so I need to verify the... ＋
Agent reasoning
The denial specifically rejects the urgent-care case-rate and specimen-handling codes, so I need to verify the appropriate new-patient office E/M replacement before changing the claim. Based on the chart’s 15-minute new-patient visit with limited documented MDM and no separately billable lab order, I am checking CPT 99202 as the likely supported code.
Args · stage denial · day 16
{"code": "99202"}
Result
{"code": "99202", "found": true, "desc": "Office/outpatient E/M, NEW patient, straightforward MDM", "category": "em_new", "patient": "new", "mdm": "straightforward"}
#22 kb_coding_guidelines The denial identifies the urgent-care case-rate/specimen codes as unsupported and notes a documented service is... ＋
Agent reasoning
The denial identifies the urgent-care case-rate/specimen codes as unsupported and notes a documented service is unbilled. Before burning a resubmission, I need the E/M leveling rules to choose the correct new-patient office code from the documented sore-throat evaluation rather than guessing between 99202 and 99203.
Args · stage denial · day 16
{"topic": "em"}
Result
{"topic": "em", "guidelines": ["Level Evaluation & Management from documented MDM (medical decision making) OR total time on the date of service - not from a term search.", "MDM has three elements (number/complexity of problems, amount/complexity of data reviewed, risk of complications); the level is the 2-of-3 that are met or exceeded.", "Do NOT default to the lowest level. Most urgent-care visits are NOT straightforward (99202/99212): an acute illness/injury that is evaluated, worked up, or tr …[truncated]
#23 kb_lookup_cpt The denial indicates the urgent-care case-rate/specimen codes were unsupported, so I need to replace them with the... ＋
Agent reasoning
The denial indicates the urgent-care case-rate/specimen codes were unsupported, so I need to replace them with the documented new-patient E/M. Before changing the claim, I’m verifying the likely low-MDM new-patient office E/M code description rather than reusing the denied codes.
Args · stage denial · day 16
{"code": "99203"}
Result
{"code": "99203", "found": true, "desc": "Office/outpatient E/M, NEW patient, low MDM", "category": "em_new", "patient": "new", "mdm": "low"}
#24 create_provider_query The denial specifically says the submitted urgent-care/global and specimen-handling codes are unsupported and that... ＋
Agent reasoning
The denial specifically says the submitted urgent-care/global and specimen-handling codes are unsupported and that documented services may be unbilled. The chart is ambiguous because the note says specimens were taken/sent to the lab, but the structured orders section shows N/A, so I need provider clarification before choosing whether to bill only an E/M or also a lab/specimen-related service.
Args · stage denial · day 16
{"topic": "diagnostic testing/specimen documentation", "question": "For the 2024-09-15 urgent-care visit for sore throat/tonsillar exudate, please clarify whether any throat specimen or diagnostic test was actually ordered, collected, performed in-office, or sent to an outside la …[truncated]
Result
{"ok": true, "query_id": "q-537198bd52", "note": "query routed to provider; awaiting response"}
#25 resolve_provider_query There is an open provider query about whether any diagnostic testing/specimen handling was actually performed, which... ＋
Agent reasoning
There is an open provider query about whether any diagnostic testing/specimen handling was actually performed, which directly affects whether 99000 or lab-related services can be billed. I need the provider’s response before correcting the denied CPT lines and resubmitting.
Args · stage denial · day 18
{"query_id": "q-537198bd52"}
Result
{"ok": true, "query_id": "q-537198bd52", "doc_state": "provider-query-resolved", "resolution": "Provider clarified specificity/laterality and confirmed medical necessity; documentation now supports final coding."}
#26 portal_download_era The claim is in adjudication denial status, and before changing coding I need the full ERA/EOB detail to confirm the... ＋
Agent reasoning
The claim is in adjudication denial status, and before changing coding I need the full ERA/EOB detail to confirm the exact denied lines, CARC/RARC wording, and any payer-specific remark beyond the summary so I do not waste a resubmission.
Args · stage denial · day 18
{}
Result
{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN383348-1\n  Status: DENIED\n  Billed:      $200.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $200.00\n  CARC: CO-16\n  RARC: M51\n    S9083: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-16 M51]\n    99000: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-16 M51]", "era": {"remit_id": "era-34211d7325", "status": "denied", "billed_cents": 20000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "co …[truncated]
#27 capture_charges The denial says the submitted urgent-care global/specimen handling lines do not match the documented professional... ＋
Agent reasoning
The denial says the submitted urgent-care global/specimen handling lines do not match the documented professional service and that documented services may be unbilled. Because the provider query has since been resolved, I need to re-aggregate the billable activities from the chart/query response before replacing the denied lines and using another submission attempt.
Args · stage denial · day 18
{}
Result
{"ok": true, "charge_feed": [{"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Infectious agent antigen detection, Streptococcus group A (rapid strep) (CLIA-waived rapid test)."}, {"source": "visit", "description": "ESTABLISHED patient office/urgent-care evaluation & management visit; 1 problem(s) addressed; total time: not documented. Read the progress note for history/exam/data ordered/risk and assign the E/M level (CPT) per the 2021 MDM …[truncated]
#28 kb_lookup_cpt The denial specifically says the submitted S9083/99000 lines are unsupported and that documented services were... ＋
Agent reasoning
The denial specifically says the submitted S9083/99000 lines are unsupported and that documented services were unbilled. The charge feed documents a CLIA-waived rapid Group A strep test, so I need to verify the correct CPT before replacing the denied lines.
Args · stage denial · day 18
{"code": "87880"}
Result
{"code": "87880", "found": true, "desc": "Infectious agent antigen detection, Streptococcus group A (rapid strep)", "category": "lab", "clia_waived": true, "keywords": ["strep", "streptococcus", "rapid strep", "group a"]}
#29 set_service_lines The denial identifies both submitted HCPCS lines as unsupported/undocumented, so I am replacing them with the... ＋
Agent reasoning
The denial identifies both submitted HCPCS lines as unsupported/undocumented, so I am replacing them with the documented professional new-patient E/M and the confirmed rapid Group A strep antigen test. I will also correct the POS from urgent-care POS 20 to the charted office POS 11 and include QW for the CLIA-waived rapid strep test.
Args · stage coding · day 18
{"lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}, {"cpt": "87880", "modifiers": ["QW"], "units": 1, "dx_pointers": [1], "place_of_service": "11"}]}
Result
{"ok": true, "service_lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}, {"cpt": "87880", "modifiers": ["QW"], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}]}
#30 set_claim_header Because the corrected claim includes an in-office diagnostic lab service, the ordering/referring provider NPI should... ＋
Agent reasoning
Because the corrected claim includes an in-office diagnostic lab service, the ordering/referring provider NPI should be populated in Box 17b before scrub/resubmission. The chart identifies Dr. Raj Patel as the rendering/ordering provider, and no prior authorization is required for these services.
Args · stage coding · day 18
{"referring_npi": "1700802145", "prior_auth_number": ""}
Result
{"ok": true, "updated": ["referring_npi", "prior_auth_number"], "claim_header": {"onset_date": "", "referring_npi": "1700802145", "referring_name": "", "prior_auth_number": "", "accident_type": "", "claim_notes": ""}}
#31 run_scrub The denied claim lines have been replaced with chart-supported CPTs (new patient E/M plus rapid strep test), so... ＋
Agent reasoning
The denied claim lines have been replaced with chart-supported CPTs (new patient E/M plus rapid strep test), so before using a remaining submission attempt I need to re-run the payer scrub on the corrected claim to catch any NCCI, modifier, medical-necessity, referring-provider, or header defects.
Args · stage coding · day 18
{}
Result
{"ok": true, "issues": [], "n_issues": 0, "note": "scrub clean"}
#32 submit_claim The denied first submission used unsupported codes (S9083, 99000). The claim has already been corrected to supported... ＋
Agent reasoning
The denied first submission used unsupported codes (S9083, 99000). The claim has already been corrected to supported documented lines (99203 and 87880-QW), scrubbed clean, and differs from the prior denied coding, so the next step is to submit the corrected 837P and obtain payer adjudication.
Args · stage denial · day 34
{}
Result
{"ok": false, "result": "835_partial", "remit": {"remit_id": "era-d29a62aacc", "status": "partial", "billed_cents": 30014, "allowed_cents": 25014, "paid_cents": 5057, "patient_resp_cents": 19957, "contractual_cents": 5000, "claim_control_number": "CCN383348-2", "lines": [{"cpt": "99203", "billed_cents": 25014, "paid_cents": 5057, "allowed_cents": 25014}, {"cpt": "87880", "billed_cents": 5000, "paid_cents": 0, "carc": "CO-4", "rarcs": ["N519"]}], "carcs": ["CO-4"], "rarcs": ["N519"], "posted": fa …[truncated]
#33 post_remittance The 835 shows a partial payment with the E/M line paid and the rapid strep line denied. I need to post the paid... ＋
Agent reasoning
The 835 shows a partial payment with the E/M line paid and the rapid strep line denied. I need to post the paid portion and patient responsibility before reworking the denied line for the final allowed resubmission.
Args · stage denial · day 34
{}
Result
{"ok": true, "posted": true, "partial": true, "note": "partial payment posted (5057 cents). 1 line(s) were denied - rework the denied line(s) and resubmit a corrected claim, or write_off the remainder if unrecoverable."}
#34 portal_download_era The second submission partially paid, but line 2 denied for modifier inconsistency. Before using the final... ＋
Agent reasoning
The second submission partially paid, but line 2 denied for modifier inconsistency. Before using the final submission attempt, I need the full ERA/EOB details to confirm the exact payer edit and whether the QW modifier is inappropriate or another modifier/CLIA requirement is implicated.
Args · stage denial · day 34
{}
Result
{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN383348-2\n  Status: PARTIAL\n  Billed:      $300.14\n  Allowed:     $250.14\n  Paid:        $50.57\n  Pt resp:     $199.57\n  Contractual: $50.00\n  CARC: CO-4\n  RARC: N519\n    99203: billed $250.14 paid $50.57 PR $0.00\n    87880: billed $50.00 paid $0.00 PR $0.00  [DENIED CO-4 N519]", "era": {"remit_id": "era-d29a62aacc", "status": "partial", "billed_cents": 30014, "allowed_cents": 25014, "paid_cents": 5057, "patient_resp_cents": 19957, "contr …[truncated]
#35 kb_lookup_payer_policy The remaining denial is specifically payer/modifier related on CPT 87880, and we only have one resubmission left. I... ＋
Agent reasoning
The remaining denial is specifically payer/modifier related on CPT 87880, and we only have one resubmission left. I need to confirm Empire BCBS modifier requirements before changing the line, especially whether QW should be removed or replaced.
Args · stage denial · day 34
{}
Result
{"payer": "BCBS OF NY EMPIRE PPO FS", "payer_class": "COMMERCIAL", "policy": {"timely_filing_days": 90, "appeal_window_days": 180, "common_denials": ["CO-167", "CO-A1", "CO-22"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 240, "appeal_levels": ["first_level_appeal", "second_level_appeal", "external_review"], "denial_timing_days": 14, "auth_required_services": ["70551", "70553", "72148", "73721", "20610"], "payer_id": "36160"}}
#36 kb_lookup_carc The remaining denial is CO-4/N519 on CPT 87880, indicating an invalid or missing modifier. Before using the final... ＋
Agent reasoning
The remaining denial is CO-4/N519 on CPT 87880, indicating an invalid or missing modifier. Before using the final submission attempt, I need to confirm the denial definition and recommended correction path for this CARC so I can adjust only the denied line appropriately.
Args · stage denial · day 34
{"carc": "CO-4"}
Result
{"code": "CO-4", "found": true, "rarcs": [{"code": "M77", "narrative": "Missing/incomplete/invalid/inappropriate place of service."}], "narrative": "Procedure code is inconsistent with the modifier used (or a required modifier is missing).", "remedy": "Append the appropriate modifier (often 25 for E/M + procedure same DOS) and resubmit.", "appealable": "yes"}
#37 kb_lookup_modifier The denial is specifically about an invalid or missing modifier on the rapid strep line, and the current line... ＋
Agent reasoning
The denial is specifically about an invalid or missing modifier on the rapid strep line, and the current line includes QW. I need to verify what QW represents before deciding whether to remove it or add a different modifier for the final allowed resubmission.
Args · stage denial · day 34
{"modifier": "QW"}
Result
{"modifier": "QW", "meaning": "CLIA-waived test."}
#38 set_service_lines The denial is specifically on line 2 for modifier inconsistency; because 87880 was submitted with QW and the payer... ＋
Agent reasoning
The denial is specifically on line 2 for modifier inconsistency; because 87880 was submitted with QW and the payer rejected the modifier, I will correct only that denied element by removing QW while keeping the paid E/M line unchanged. This creates a new coding combination that has not already been submitted and preserves the chart-supported services.
Args · stage coding · day 34
{"lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}, {"cpt": "87880", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}]}
Result
{"ok": true, "service_lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}, {"cpt": "87880", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}]}
#39 kb_coding_guidelines The denial is specifically modifier-related on 87880, and the prior retry apparently included QW but still denied,... ＋
Agent reasoning
The denial is specifically modifier-related on 87880, and the prior retry apparently included QW but still denied, so before burning the last submission I need to confirm the payer-specific billing rule for this lab/modifier combination and any Empire companion-guide requirements.
Args · stage coding · day 34
{"topic": "modifiers"}
Result
{"topic": "modifiers", "guidelines": ["25: significant, separately identifiable E/M on the same day as a procedure/test (unbundles the E/M).", "59 / XE / XS / XP / XU: distinct procedural service - unbundles an NCCI pair when the services were genuinely separate.", "95: synchronous telemedicine (real-time audio/video).", "QW: CLIA-waived in-house test. RT/LT/50: laterality / bilateral.", "Check an NCCI procedure pair with kb_lookup_ncci cpt_a=.. cpt_b=.. and a modifier's meaning with kb_lookup_m …[truncated]
#40 run_scrub The denial was specific to the rapid strep line’s modifier, and the claim has now been changed from the previously... ＋
Agent reasoning
The denial was specific to the rapid strep line’s modifier, and the claim has now been changed from the previously denied 87880-QW configuration to 87880 without QW. Before using the final submission, I need to run the payer scrub to confirm the revised service lines, modifier use, NCCI, and referring/order fields are clean.
Args · stage coding · day 34
{}
Result
{"ok": true, "issues": [], "n_issues": 0, "note": "scrub clean"}
#41 submit_claim The denied line was 87880 with modifier QW; I have corrected the service line to remove the invalid modifier,... ＋
Agent reasoning
The denied line was 87880 with modifier QW; I have corrected the service line to remove the invalid modifier, verified the claim now differs from the prior submission, and the scrub is clean. With only one submission remaining, the appropriate next step is to transmit the corrected 837P and obtain payer intake/adjudication responses.
Args · stage remittance · day 50
{}
Result
{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-bf51162054", "status": "paid", "billed_cents": 30014, "allowed_cents": 30014, "paid_cents": 6068, "patient_resp_cents": 0, "contractual_cents": 23946, "claim_control_number": "CCN383348-3", "lines": [{"cpt": "87880", "billed_cents": 5000, "allowed_cents": 5000, "paid_cents": 375, "patient_resp_cents": 0, "contractual_cents": 4625}, {"cpt": "99203", "billed_cents": 25014, "allowed_cents": 25014, "paid_cents": 5693, "patient_resp_cents" …[truncated]
#42 post_remittance The latest 835 for CCN383348-3 is paid with no CARCs/RARCs and patient responsibility is $0.00, so the remaining... ＋
Agent reasoning
The latest 835 for CCN383348-3 is paid with no CARCs/RARCs and patient responsibility is $0.00, so the remaining required revenue-cycle step is to post the ERA and reconcile the balance. I will post the remittance to close out the paid claim.
Args · stage closed_paid · day 50
{}
Result
{"ok": true, "posted": true, "note": "ERA posted; case closed paid"}